Fill and Sign the Indiana Name Change Form

STATE OF INDIANA ) IN THE       CIRCUIT COURT ) SS: COUNTY OF       ) CASE NO.       IN RE CHANGE OF ) NAME OF MINOR: )       ) )       ) Petitioner. ) CONSENT TO CHANGE OF NAME OF MINOR I, the non-petitioning party, make the following declarations: 1. My full name is       . 2. I reside at:             3. I am the non-petitioning father/mother/guardian of the Minor Child. 4. Pursuant to Indiana Code 34-28-2-2, I hereby consent to the Minor Child’s name to be changed from       to       . 5. This consent is executed by me without coercion or duress and is irrevocable. 6. The petitioning parent or guardian of the Minor Child has served me with a copy of Petition for Change of Name of Minor as required by Indiana Trial rules. WHEREFORE, I affirm under the penalties of perjury that the foregoing representations are true. Signature (Parent)(Guardian)       (Parent)(Guardian) Printed Name       Mailing Address       Town, State and Zip Code       Telephone Number, with Area Code Page 1 of 1 Form PS-34282-6 Approved by State Court Administration 12/10 Page 2 of 1 Form PS-34282-6 Approved by State Court Administration 12/10